Role of vacuum assisted excision in minimising overtreatment of ductal atypias.

PURPOSE: B3 lesions are indeterminate lesions of uncertain malignant potential. They include lesions with and without epithelial atypia. Those with atypia include atypical intraductal epithelial proliferation (AIDEP)/atypical ductal hyperplasia (ADH) and flat epithelial atypia (FEA). They are traditionally managed with surgery. Vacuum assisted excision (VAE) allows larger samples to be obtained using a vacuum assisted biopsy (VAB) device, which equates to a surgical biopsy. We propose that VAE and mammographic surveillance is a safe alternative to surgery in managing the ductal atypias; (AIDEP/ADH and FEA). METHOD: Retrospective analysis of prospectively collected data on B3 lesions (April 2009 - March 2016) from consecutive breast screening patients diagnosed with AIDEP/ADH or FEA on initial diagnostic core biopsy. Mammographic abnormality, breast density, size, management pathway and upgrade to cancer and types of cancer were also collected during the treatment pathway and 5 year surveillance period (April 2009 - April 2019). RESULTS: 273 cases of ductal atypia were identified. 187/273 (68.5 %) cases were managed with VAE only as no upgrade to malignancy and then 5 year mammographic surveillance. 34/273 (12.5 %) cases had a VAE diagnosing malignancy. 24/273 (8.8 %) cases had a VAE and then a surgical biopsy due to radiological or pathological concern, 8/24 upgraded to malignancy. 22/273 (8%) cases had a surgical diagnostic biopsy, 9/22 (41 %) cases were upgraded to malignancy. In total 51/273 (19 %) cases were diagnosed with cancer on the new pathway (13 invasive (all ER positive and Her2 negative) and 38 non-invasive, (34 ductal carcinoma in situ (DCIS) and 4 cases of lobular carcinoma in situ (LCIS)). While 17/273 (6.2 %) cases developed malignancy (12 invasive (all HER2 negative) and 4 DCIS and 1 LCIS) during the 5 year surveillance period. CONCLUSIONS: VAE is a safe alternative to surgery in managing ductal atypias. 187/273 (68.5 %) women avoided surgery. While 34/51 cancers (66.7 %) were diagnosed preoperatively using VAE, allowing the women to have a single therapeutic procedure.

CT staging for breast cancer patients with poor prognostic tumours.

The aim of this study was to assess the value of computed tomography (CT) staging of the chest, abdomen and pelvis in patients with poor prognostic tumours and no symptoms of metastatic disease in those who have undergone primary surgical management for the treatment of breast cancer. Patients who had primary operable invasive breast cancer treated by surgery over a 2-year period were retrospectively identified. Pathological data from the surgical resection were used to calculate the Nottingham Prognostic Index. Patients with no symptoms of distant metastases who underwent CT staging of the chest, abdomen and pelvis as a result of being placed in the poor prognostic group were identified. The presence and sites of metastatic disease or any indeterminate finding were documented. Additional investigations generated as a result of the staging CT and the outcome were also recorded. Sixty-seven patients (80%) in the poor prognostic group underwent a staging CT. Forty-seven patients (70%) had no signs of metastatic disease on the staging CT. Two patients (3%) were diagnosed with metastatic disease, on the basis of the initial CT scan. Eighteen patients (27%) had an indeterminate finding requiring further investigation, generating 21 additional imaging tests - following this only one additional patient was diagnosed with metastatic disease. Seventeen patients with an initially indeterminate finding did not have metastatic disease, giving a false-positive rate of 25%. In total, three patients (4%) had a final diagnosis of metastatic disease. The routine use of CT staging in patients with no symptoms of distant metastases with primary operable breast cancer even when in a poor prognostic group is of limited value, with a low pick-up rate of metastatic disease and considerable risk of false-positive findings.

Does the insertion of a gel-based marker at stereotactic breast biopsy allow subsequent wire localizations to be carried out under ultrasound guidance?

AIM: To investigate whether the insertion of a gel-based marker at the time of stereotactic breast biopsy allows subsequent preoperative localization to be performed under ultrasound guidance. MATERIALS AND METHODS: One hundred consecutive women who underwent either a 10 G stereotactic vacuum-assisted breast biopsy or 14 G stereotactic core biopsy with marker placement, followed by wire localization and surgical excision were identified. All had mammographic abnormalities not initially visible with ultrasound. The method of preoperative localization was recorded and its success judged with reference to the wire position on the post-procedure films relative to the mammographic abnormality and the marker. Histopathology data were reviewed to ensure the lesion had been adequately excised. RESULTS: Eighty-three women (83%) had a successful ultrasound-guided wire localization. Successful ultrasound-guided localization was more likely after stereotactic vacuum biopsy (86%) compared to stereotactic core biopsy (68%), although this did not quite reach statistical significance (p=0.06). CONCLUSION: The routine placement of a gel-based marker after stereotactic breast biopsy facilitates preoperative ultrasound-guided localization.

Molecular characterisation of the recA locus in clinical isolates of verocytotoxigenic E. coli O157:H7.

Molecular epidemiology of verocytoxigenic Escherichia coli O157:H7 is important to help elucidate reservoirs and modes of transmission, particularly between animals and humans. As the recA gene locus is now beginning to gain application in bacterial genotyping schemes, and as it has not been examined previously in E. coli O157 isolates, this study aims to examine potential polymorphic variation as a possible epidemiological marker for the subspecies characterisation of clinically significant verocytotoxigenic E. coli O157:H7. A novel polymerase chain reaction (PCR) assay was designed to target a 638 bp region of the recA gene in E. coli O157 isolates. The PCR amplification of genomic DNA from extracted organisms was able to generate an amplicon of the expected size (approximately 638 bp) for all E. coli O157:H7 examined (n=80), as well as for other non-O157 E. coli and other members of the Enterobacteriaeceae including Citrobacter, Hafnia, Shigella, Enterobacter and Providencia. Subsequent restriction fragment length polymorphism (RFLP) and single-stranded conformational polymorphism (SSCP) analyses of these recA amplicons were able to differentiate E. coli O157 from the organisms examined, but were unable to distinguish between 79 isolates of wild-type E. coli O157, suggesting a highly conserved recA gene structure within the local population of organisms examined.

Changes in antibiotic susceptibility in staphylococci habituated to sub-lethal concentrations of tea tree oil (Melaleuca alternifolia).

AIMS: To investigate the effect of sub-lethal challenge with tea tree oil (TTO) on the antibiotic resistance profiles of staphylococci. METHODS AND RESULTS: Isolates of methicillin-resistant/-sensitive Staphylococcus aureus (MRSA and MSSA) and coagulase-negative staphylococci (CONS) were habituated to sub-lethal concentrations of TTO (72 h). Following habituation, the minimum inhibitory concentrations (MIC) of antibiotics and TTO were determined. Habituated MRSA/MSSA cultures had higher (P < 0.05) MIC values than control cultures for the examined antibiotics. Habituated MRSA/MSSA cultures also displayed decreased susceptibility to TTO. Although the MIC of habituated MRSA/MSSA for the examined antibiotics reverted to control values after subsequent culture in the absence of TTO, the increased MIC against TTO were maintained. When compared with control cultures, habituated CoNS cultures had higher (P < 0.05) MIC values against three-fifths of the antibiotics examined; no changes in TTO MIC were observed. CONCLUSIONS: TTO habituation 'stress-hardens' MRSA and MSSA, evidenced by transient decreased antibiotic susceptibility and stable decreased TTO susceptibility. Although TTO habituation did not decrease susceptibility of CoNS to TTO, such cultures showed transient decreased antibiotic susceptibility. SIGNIFICANCE AND IMPACT OF THE STUDY: Application of TTO at sub-lethal concentrations may reduce the efficacy of topical antibiotics used with TTO in combination therapies.

The pattern of pleiomorphism in stressed Salmonella Virchow populations is nutrient and growth phase dependent.

AIMS: To describe the interactions of imposed osmotic and nutritional stress on the morphology of stationary and exponential phase S. Virchow cells. METHODS AND RESULTS: This study examined the morphology and viability of osmotically stressed exponential and stationary phase cultures of Salmonella Virchow under nutritionally deficient and competent conditions. In addition to normal morphology, salt-stressed cultures exhibited filamentous and spherical morphotypes, which were capable of reversion to normal morphology on stress removal. Proportions of atypical morphotypes were influenced by the phase of growth when the stress was applied. Salt-stressed exponential phase populations contained 54% filamentous, 30% spherical forms, salt-stressed stationary phase populations contained 16% filamentous, 79% spherical forms. Proportions of morphotypes were also influenced by the nutrient status of the medium, but not by metabolic by-products. CONCLUSIONS: Development of a range of morphotypes in response to stress (osmotic/nutritional), may offer population level advantages, increasing the survival potential of the population. SIGNIFICANCE AND IMPACT OF STUDY: The application of sublethal concentrations of salt may stimulate S. Virchow morphotype diversity, improving survival and rates of poststress recovery.

Recurrence of Kawasaki disease in an adult patient with cholecystitis.

We report recurrence of Kawasaki disease in a 20-year-old man eighteen years after the primary episode. Athough sixty-nine cases have been reported among adults in the literature, this represents only the second case of Kawasaki disease recurring in an adult patient after childhood presentation. Our patient presented with the characteristic mucocutaneous features, fever, arthralgia, epigastric pain and cholecystitis. His presentation was complicated by arthralgias and abnormal liver function tests, which are more common in the adult patient. The diagnosis was made based on clinical findings after the exclusion of other causes of persistent febrile illness. He was successfully treated with high dose aspirin and intravenous immunoglobulin therapy. Despite a second presentation of Kawasaki disease our patient did not have any demonstrable coronary arterial involvement. Although typically a self-limiting disease, cardiac complications can cause significant morbidity and mortality in those not treated with aspirin and IVIG. This report serves to highlight that late recurrence of Kawasaki disease may develop in adults many decades after the initial presentation. A twenty-year-old male, presented to the Emergency department with a one-week history of general malaise. He complained of sore throat, 5-day history of fever (39 degree celsius), epigastric discomfort, rash, nausea, vomiting, generalised arthralgia and myalgia. He was jaundiced with dark urine and pale stools. He had been commenced on oral penicillin three times a day for possible streptococcal infection after the rash had occurred. Past medical history was notable for a previous episode of Kawasaki disease (KD) at 2 years of age, after which there were no adverse sequelae, a history of asthma and non-alcoholic fatty liver disease.

Association between paclitaxel and necrotic pancreatitis.

To our knowledge this is the first reported case of paclitaxel associated necrotic pancreatitis requiring a pancreatic necrostomy. This was a near fatal complication associated with paclitaxel with a high resulting morbidity. Although this is a rare association physicians should be wary of the potential to develop severe pancreatitis in patients receiving this therapeautic agent. Monitoring of serum amylase during therapy is therefore warranted.

The prevalence of antiphospholipid antibody syndrome among systemic lupus erythematosus patients.

Systemic lupus erythematosus (SLE) is an autoimmune disease characterised by excess autoantibody production. It typically affects women of childbearing age. Antiphospholipid antibody syndrome (APLAs) is associated with serious co-morbidity to mother and child characterized by recurrent vascular thrombosis and/or pregnancy associated morbidity. We reviewed SLE patients attending a specialist connective tissue disease clinic both to assess the occurrence of APLAs and its clinical presentations and to audit the effectiveness of screening for APL antibodies in a specialist clinic. 204 patients attended the newly established connective tissue disease outpatient clinic over a twenty-seven month period; 42 (34 female, 8 male) with a diagnosis of SLE. Ten patients (24%), eight female and 2 male with a median age of 38.5 years (range 20 to 64 years) fulfilled the ACR criteria for secondary APLAs (Table 2). The commonest clinical presentation was pulmonary embolus (five patients). Overall 37 patients (88%) with SLE were screened for APLAs during the study period: 94% of females and 62.5% of males were screened (for anticardiolipin antibodies, lupus anticoagulant or both), 27% had evidence of APLAs, 24% had positive antibodies but were asymptomatic. There is a significant occurrence of APLAs among SLE patients. Given the important clinical implications of this disorder including substantial risk of fetal loss and patient morbidity or mortality, routine screening of all SLE patients for APL antibodies is recommended.

Sibling adjustment to pediatric traumatic brain injury: a case-controlled pilot study.

OBJECTIVE: To assess depressive symptoms, self-concept, and behavior in non-affected siblings of children with severe pediatric traumatic brain injury (TBI). DESIGN: Cross-sectional study with case controls. SETTING: Children's hospital tertiary care center. PARTICIPANTS: Twelve siblings of children consecutively admitted to an inpatient rehabilitation unit after a severe TBI. Case controls were randomly selected from the sibling's classmates. MAIN OUTCOME MEASURES: The Child Behavior Checklist (CBCL), the Teacher's Report Form of the CBCL (TRF-CBCL), the Self-Perception Profile for Children and the Children's Depression Inventory (CDI). RESULTS: No statistical differences were found in depressive symptoms, self-concept, or behavior between the siblings and their classmates 3 to 18 months after injury. Poorer functional outcomes in the child with a TBI were found to correlate significantly with lower self-concept and more symptoms of depression in the siblings. CONCLUSIONS: Further research is needed to evaluate the potential impact on sibling adjustment after pediatric TBI.

The occurrence of enteric pathogens and Aeromonas species in organic vegetables.

A range of commercially available organic vegetables (n = 86) was examined for the presence of Salmonella, Campylobacter, Escherichia coli, E. coli O 157. Listeria and Aeromonas spp., to provide information on the occurrence of such organisms in organic vegetables in Northern Ireland. The study was not designed to quantify such organisms or to compare occurrence with conventionally farmed vegetables. Standard enrichment techniques were used to isolate and identify enteric pathogens and Aeromonas species. No Salmonella, Campylobacter, E. coli. E. coli O 157, Listeria were found in any of the samples examined. Aeromonas species were isolated from 34% of the total number of organic vegetables examined. Many (64%) of the organic vegetables examined were "ready-to-eat" after minimal processing, i.e., washing. Aeromonas spp. was isolated from 41% of these vegetables. Aeromonas spp. was not recovered from certain vegetable types. The most commonly isolated species of Aeromonas was Aeromonas schubertii with 21.0% of all samples contaminated with this species; 5.8% of samples contained A. hydrophila, 5.8% A. trota, 3.5% A. caviae and 2.3% contained A. veronii biovar veronii. Although Aeromonas species are frequently detected in organic vegetables, the absence of accepted enteric pathogens was encouraging, and does not support the allegation of organic foods being of high risk due to the farming methods used.

The expression of proteinases and haemolysins by Aeromonas hydrophila under modified atmospheres.

The study estimated the proteolytic activity (against Hide Powder Azure) and haemolytic activity (against horse erythrocytes) in cell-free filtrates (CFF) from four strains of Aeromonas hydrophila growing under a range of commercially relevant modified atmospheres (2% O2, 78% N2, 20% CO2; 10% O2, 80% N2, 10% CO2; 50% N2, 50% CO2; 100% CO2). The examined strains exhibited significant qualitative and quantitative differences in the extent and times of onset of expression of these enzymes under aerobic and modified atmospheres. No proteolytic or haemolytic activities were detected in any Aer. hydrophila cultures grown at sub-optimal temperatures under modified atmospheres containing high concentrations of CO2 (i.e. 50% CO2 or 100% CO2). Although Aer. hydrophila can grow rapidly in modified atmospheres, the overall spoilage and pathogenic potential is grossly affected. Implications of these findings are discussed.

Osteoporosis: identifying high-risk persons.

Osteoporosis is the most common systemic bone disorder causing thousands of injuries and deaths each year. The pathogenesis of osteoporosis is a complex puzzle that contains many interlocking pieces involving both genetic and environmental factors. The prevention of age-related bone loss, which could be gained through health teaching by the nurse, should be optimized. Nurses and other caregivers can make significant contributions toward the initial identification of those persons at risk or who may already have the debilitating disease by using the Osteoporosis Risk Questionnaire.

Visual cerebral lateralization over phases of the menstrual cycle: a preliminary investigation.

This study investigated whether visual cerebral asymmetries would change in phase with hormonal variations during the menstrual cycle. Lexical decision and line orientation tasks were administered during follicular, luteal, and menstrual phases of each woman's cycle. These tasks were also administered to a reference group of male subjects. Signal detection analyses indicated an unvarying RVF advantage in word/nonword discriminability (d') throughout the menstrual cycle, but a phase-dependent shift in left hemisphere response criterion (log beta). Gender differences were present for discriminability of line orientation, and female performance on this task varied over the cycle. The results imply that the neural systems subserving some cognitive functions are sensitive to fluctuations in gonadal steroids and suggest a hormonal basis for gender differences in some visual-spatial functions.